Prescribing Cascades with Recommendations to Prevent or Reverse Them: A Systematic Review

BACKGROUND

To reduce prescribing cascades occurring in clinical practice, healthcare providers require information on the prescribing cascades they can recognize and prevent.

OBJECTIVE

This systematic review aims to provide an overview of prescribing cascades, including dose-dependency information and recommendations that healthcare providers can use to prevent or reverse them.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Relevant literature was identified through searches in OVID MEDLINE, OVID Embase, OVID CINAHL, and Cochrane. Additionally, Web of Science and Scopus were consulted to analyze reference lists and citations. Publications in English were included if they analyzed the occurrence of prescribing cascades. Prescribing cascades were included if at least one study demonstrated a significant association and were excluded when the adverse drug reaction could not be confirmed in the Summary of Product Characteristics. Two reviewers independently extracted and grouped similar prescribing cascades. Descriptive summaries were provided regarding dose-dependency analyses and recommendations to prevent or reverse these prescribing cascades.

RESULTS

A total of 95 publications were included, resulting in 115 prescribing cascades with confirmed adverse drug reactions for which at least one significant association was found. For 52 of these prescribing cascades, information regarding dose dependency or recommendations to prevent or reverse prescribing cascades was found. Dose dependency was analyzed and confirmed for 12 prescribing cascades. For example, antipsychotics that may cause extrapyramidal syndrome followed by anti-parkinson drugs. Recommendations focused on dosage lowering, discontinuing medication, and medication switching. Explicit recommendations regarding alternative options were given for three prescribing cascades. One example was switching to ondansetron or granisetron when extrapyramidal syndrome is experienced using metoclopramide.

CONCLUSIONS

In total, 115 prescribing cascades were identified and an overview of 52 of them was generated for which recommendations to prevent or reverse them were provided. Nonetheless, information regarding alternative options for managing prescribing cascades was scarce.

Aerobic exercise in pregnancy

The effect on fetal and maternal outcome in gestational exercise in a recreational athlete was investigated in a 2 1/2-year prospective study. A training effect in a pregnant subject engaged in aerobic exercise was also determined. One hundred forty-one low-risk pregnant subjects had their aerobic capacity tested during the first trimester, during the third trimester, and post partum. Predicted maximum oxygen consumption values were determined by using standard Bruce treadmill protocol during the first and third tests and the Astrand protocol for submaximal testing on a bicycle ergometer during the third trimester. Exercise prescriptions were given. The primiparous and multiparous subjects were randomized into control and exercise groups, differing only in the frequency of aerobic exercise. The results showed that exercise had no associated increase in neonatal morbidity and obstetric complications. All subjects improved or maintained their level of aerobic fitness. The exercisers showed a significant training effect. The disparity in the second test's results may suggest that the physiologic characteristics of pregnancy masked the aerobic improvement.